A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?
Call the provider for a stat DNR order.
Call the emergency response team.
Seek immediate help from the risk manager.
Respect the family's wishes and do nothing.
The Correct Answer is B
Rationale:
A. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.
B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.
C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.
D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. The name of the provider who prescribed the medication is not necessary for the variance report; focus should be on the incident itself.
B. The time the client was to receive the medication should be included to document the discrepancy accurately.
C. The date of the incident is essential for accurate record-keeping and follow-up.
D. The client's vital signssuch as blood pressure are especially relevant for medications like furosemide, which affects fluid balance and blood pressure. These values help assess for harm or trends following the missed dose.
E. The potential adverse effects of the medication are not typically included in the incident report but might be noted in the client's ongoing care plan.
Correct Answer is A
Explanation
Rationale:
A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.
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